5210/15 Legal Support Services (LSS) Provider Budget Form

OMB Number: 3064-0122
Expiration Date: 01/31/2023

Federal Deposit Insurance Corporation

LEGAL SUPPORT SERVICES (LSS) PROVIDER BUDGET

PAPERWORK REDUCTION ACT NOTICE
Public reporting burden for this collection of information is estimated to average 1.0 hour per response, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection
of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including
suggestions for reducing this burden, to the Paper Reduction Act Clearance Officer, Legal Division, Federal Deposit Insurance
Corporation, 550 17th Street, N.W., Washington, D.C. 20429, and the Office of Management and Budget, Paperwork Reduction
Project (3064-0122), Washington, D.C. 20503. Any agency may not conduct or sponsor, and a person is not required to respond to, a
collection of information unless it displays a currently valid OMB control number.
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FDIC 5210/15 (5-21)

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OMB Number: 3064-0122
Expiration Date: 01/31/2023

Federal Deposit Insurance Corporation

LEGAL SUPPORT SERVICES (LSS) PROVIDER BUDGET
INSTRUCTIONS: Please provide all information requested.
SECTION I - INSTITUTION INFORMATION
1. Matter Number

3. Institution Type:

2. Matter Caption

Bank

Thrift

4. LSS Firm/Provider Name

Institution Number:
SECTION II - BUDGET INFORMATION
5. Fees

6. Estimated Recovery Value

Hourly Rate (Rate Schedule must be attached)
Fixed Fee
Contingent Fee
7. Specify Nature of Work to be Performed

8. Complete the following.
Action

Fee

Expense

Total

Court Services Reporting Services
Appraisal
Copy/Imaging Services
Escrow Services
Registered Agent Services
Title Company Services
Other Services (Specify):
Grand Total of Budget
9. Estimated Hours for Completion:
10. Estimated Completion Date:
SECTION III - LSS FIRM/PROVIDER BUDGET ACKNOWLEDGMENT
I acknowledge that the budget information contained herein is correct to the best of my knowledge and written approval of the FDIC
Legal Division is required for any increase in the total budget amount.
11. Name of Authorized LSS

12. Title of Authorized LSS

15. Signature of Authorized LSS

13. Telephone

14. Fax

16. Date

SECTION IV - BUDGET AUTHORIZATION FOR LSS FIRM/PROVIDER TO PROCEED
17. Signature of FDIC Attorney (Recommending Approval of Budget)

18. Date

19. Signature of FDIC Delegated Authority

20. Date Budget Approved

FDIC 5210/15 (5-21)

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